Chronic Subdural Hematoma - Symptoms, Causes & Treatment

A chronic subdural hematoma is a situation in which blood slowly leaks and accumulates over the surface of the brain, thus forming a clot. It usually results from a head injury that causes the tearing of small veins, allowing blood to slowly leak into the subdural space over days to weeks.

Chronic SDH are more common in older adults because the brain naturally shrinks with age, stretching the veins and making them more prone to tearing.

Acute vs Chronic Subdural Hematoma

A patient can experience either acute vs chronic subdural hematoma. Here is the difference between them:

1. Acute Subdural Hematoma: Develops rapidly after a severe head injury

2. Chronic Subdural Hematoma: Progresses slowly over weeks or months, often after a minor injury

Chronic subdural hematomas can be classified based on the type of bleeding. The following are the main types:

1. Simple: A single clot between the dura mater and the brain. It results from slow venous bleeding and does not have multiple compartments or significant rebleeding.
2. Complex: Multiple divisions within the hematoma. It may involve repeated episodes of bleeding. As a result, a longer chronic subdural hematoma duration is required.
3. Acute on Chronic SDH: Occurrence of bleeding into an existing chronic subdural hematoma. It can lead to a sudden increase in symptoms and may require urgent medical intervention.
4. Calcified: Calcification (hardening) happens when there is an excess of calcium in the body. In some cases, the hematoma may become hardened over time.

Grades of Chronic Subdural Hematoma

Chronic subdural hematoma can be classified into different grades based on the severity and clinical presentation. The common grades are as follows:

The symptoms can be subtle and may develop slowly, often weeks or months after the initial bleeding. Here are the common signs:

1. Headaches: Persistent and worsening over time
2. Confusion: Difficulty thinking clearly or making decisions
3. Drowsiness: Excessive sleepiness or lethargy
4. Nausea and Vomiting: Often accompanying headache
5. Trouble Walking: Trouble with balance and coordination
6. Impaired Memory: Problems with short-term memory
7. Vision Problems: Blurred or double vision
8. Speech Difficulties: Trouble speaking or swallowing
9. Seizures: Sudden, uncontrolled electrical disturbances in the brain
10. Weakness or Numbness: Particularly on one side of the body, affecting arms, legs, or face
11. Personality Changes: Mood swings or changes in behaviour

"In my experience, I once encountered a 72-year-old gentleman presenting with recurring headaches and confusion. A detailed neurological examination with imaging showed a chronic subdural hematoma.

It was potentially exacerbated by anticoagulant therapy for his cardiac condition. Quick surgical treatment led to significant neurological improvement. This highlights the role of timely medical attention in treating such cases."

- Dr. Himanshu Champaneri

Neuro Surgeon MBBS, MS General Surgery

The most common cause of chronic subdural hematoma is minor head injury. It can lead to the tearing of bridging veins in the subdural space. This results in slow bleeding and the formation of a hematoma over time.

Several factors can increase the risk of developing chronic subdural hematoma. Common aspects include the following:

1. Age: Older adults (above 50 years of age) are more susceptible to it due to brain atrophy. It increases the subdural space and makes the bridging veins more vulnerable to tearing, even with minor trauma.

2. Alcohol Misuse: Regular liquor consumption can weaken blood vessels and increase the risk of bleeding, contributing to the development of the condition.

3. Medications: The use of blood-thinning medicines. It can increase the risk of bleeding and the formation of a subdural hematoma.

4. Coagulopathies: Conditions that affect blood clotting, such as haemophilia or anticoagulant therapy, can also be a cause.

5. Seizures: It can lead to falls and head injuries, which may result in the formation of a subdural hematoma.

6. Previous Neurosurgery: Patients undergoing neurosurgical procedures, such as shunt surgeries, are at increased risk. This is due to potential trauma during surgery and changes in intracranial pressure.

7. Chronic Diseases: Patients with conditions like liver cirrhosis and chronic renal failure, which affect blood clotting and vascular integrity.

Preventing chronic subdural hematoma involves several strategies. These are aimed at reducing the risk of head injuries and managing underlying conditions:

1. Protective Gear: Wearing helmets during biking, motorcycling, skiing, and contact sports like wrestling and fencing.
2. Fall Prevention: It is beneficial to take precautions to prevent falls, especially in the elderly. This includes using handrails and installing grab bars in bathrooms.
3. Medication Management: It is important to regularly review the medicines with a healthcare provider, especially for those taking anticoagulants or antiplatelet drugs.
4. Avoiding Liquor Misuse: Reducing or eliminating alcohol consumption can lower the risk of head injuries and bleeding. Regular use can weaken blood vessels and impair balance.
5. Regular Check-Ups: This can help manage conditions like hypertension and coagulopathies, increasing the risk of the disease.
6. Healthy Lifestyle: Moving towards an active life with a balanced diet, regular exercise, and avoiding smoking can improve overall health.

Diagnosing a chronic subdural hematoma involves the use of various diagnostic tools. Here is a detailed explanation:

1. Physical Examination: The neurosurgeon will inquire about any recent head injuries, symptoms, and the overall health of the patient. 

2. Imaging Tests: Various evaluations are required to assess the presence of the disease. These include:

1. Computed Tomography (CT) Scan: It is the most commonly used imaging test for diagnosing the disease. It provides detailed images of the brain.
2. Magnetic Resonance Imaging (MRI): These scans offer more detailed images than CT scans. It is a better option for detecting subtle changes in brain tissue. 

3. Paraclinical Investigations: Blood tests are conducted to examine bleeding disorders and measure clotting. 

How to prepare for a doctor consultation?

Preparing for a consultation with a neurosurgeon is essential for the patient. Here are some steps to prepare effectively:

1. Gather all previous medical records, including any imaging tests (CT scans, MRIs), blood tests, and other reports.

2. Compile a list of all current medications, including prescription drugs and supplements.

3. Patients should also document all symptoms they are experiencing, their frequency, and how they affect daily life.

Questions to Ask the Doctor

Before visiting a clinic or hospital, having a list of questions ready can help the patient clear all underlying doubts. Here are some common examples:

1. What is the best treatment option for my condition?

2. What are the potential risks of the treatment?

3. How will this condition affect my day-to-day life?

4. Are there any lifestyle changes I should make?

5. What is the prognosis for my condition?

6. How often will I need follow-up appointments?

This condition can be treated using both surgical and non-surgical methods. Here are the chronic subdural hematoma treatment options:

1. Medication: Various drugs can be used to manage the disease, especially in patients who are not suitable for surgery. These are:

1. Steroids (e.g., Dexamethasone): Used to reduce inflammation and hematoma size.
2. Atorvastatin: Shown to help in reducing hematoma volume and preventing recurrence.
3. Tranexamic Acid: Used to reduce bleeding and promote hematoma absorption.

2. Surgical Treatments: Various surgeries can be performed to treat the condition. These comprise of:

1. Burr Hole (BH) Trephination: The most common surgical method where small holes are drilled into the skull to drain the hematoma. It is preferred due to its simplicity and effectiveness.
2. Twist Drill (TD) Craniostomy: This procedure involves using a twist drill to create a small opening for drainage. It is less invasive than traditional craniotomy.
3. Craniotomy: This surgery involves removing a larger section of the skull to access and remove the hematoma. It is typically reserved for more complex or recurrent cases.

3. Adjuvant Options: Additional therapies can be used to enhance the effectiveness of the primary treatment. Here are the options:

1. Embolisation of the Middle Meningeal Artery (EMMA): Bocking the blood supply to the hematoma to prevent its growth and recurrence. 
2. Lumbar or Ventricular Injection: Reducing the subdural space and promoting brain re-expansion.

Chronic Subdural Hematoma Survival Rate

The chronic subdural hematoma treatment has shown evident advancements and high efficacy over the years. However, the prognosis and survival rate for the condition vary significantly based on its complexity and the technique chosen for addressing it.

Certain global studies, like Rahal et al., 2023, showed a low mortality rate of 4%, and UCLA reported that 80-90% of patients had high brain functionality after surgery.

Cost of Treatment for Chronic Subdural Hematoma

The total expenditure on treating chronic subdural hematoma in India can vary significantly based on the hospital, the condition severity, and the treatment required. 

Delaying treatment can lead to severe risks. These chronic subdural hematoma complications include:

1. Increased Intracranial Pressure: As the hematoma grows, it can increase pressure within the skull, leading to brain herniation (protrusion).
2. Neurological Deterioration: Delayed treatment can result in severe symptoms affecting the sensory organs. These include worsening headaches, confusion, and motor impairments.
3. Seizures: Untreated chronic subdural hematoma can lead to seizures.
4. Cognitive Decline: Prolonged pressure on the brain can significantly affect memory, thinking, and overall mental function.
5. Recurrent Bleeding: The risk of this situation increases with delayed treatment. It happens especially in older adults or those on anticoagulant therapy.

When to call a doctor?

Early diagnosis and treatment can prevent severe chronic subdural hematoma complications and improve outcomes. It is important to seek medical attention in the below-mentioned cases:

1. Persistent or worsening headaches
2. Confusion or cognitive changes
3. Seizures
4. Weakness or numbness
5. Difficulty walking or balance issues
6. Nausea and vomiting

Diet for Chronic Subdural Hematoma

Proper nutrition is vital in the recovery process and management of the disease. Here are some dietary recommendations :

1. Lean Proteins: Inclusion of lean meats, fish, nuts, and eggs in the diet.
2. Fruits and Vegetables: Consumption of a variety of fruits and vegetables, which are rich in antioxidants and fibres.
3. Healthy Fats: Include sources of healthy fats like avocados, seeds, nuts, and olive oil.
4. Hydration: Drink plenty of fluids, particularly water, to stay hydrated.

These are certain food and beverage items that the patient must avoid:

1. Alcohol and drugs
2. High-sodium foods
3. Fatty and cholesterol
4. Sugary foods and drinks

Chronic subdural hematoma is a serious condition that requires timely medical interventions. Early diagnosis and appropriate treatment, such as burr hole trephination or craniotomy, can significantly improve patient outcomes and reduce the risk of recurrence. 

Are you or a loved one experiencing chronic subdural hematoma symptoms like persistent headaches, confusion, or weakness? If yes, HexaHealth offers comprehensive support for the disease, connecting you with expert doctors and providing end-to-end assistance. Our dedicated team ensures that you receive the best possible care tailored to your specific needs.